Provider Demographics
NPI:1215453659
Name:LAC COURTE OREILLES GOVERNING BOARD
Entity type:Organization
Organization Name:LAC COURTE OREILLES GOVERNING BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CCS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-699-1695
Mailing Address - Street 1:13380 W TREPANIA RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2186
Mailing Address - Country:US
Mailing Address - Phone:715-699-1695
Mailing Address - Fax:715-634-6107
Practice Address - Street 1:13380 W TREPANIA RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-2186
Practice Address - Country:US
Practice Address - Phone:715-699-1695
Practice Address - Fax:715-634-6107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAC COURTE OREILLES GOVERNING BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health